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General NPI Number Information
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NPI Number | 1336767748
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Entity Type | Individual
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Provider Name | ZACKERY JOHNSON
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Gender | Male
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Dates
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Enumeration Date | 07/12/2020
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Last Update Date | 07/12/2020
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Provider Practice Location Address
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Address Line | 6051 U S HIGHWAY 49
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City | HATTIESBURG
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State | MS
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Zip | 39401-7200
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Country | US
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Telephone | 601-288-4242
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Fax |
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Provider Business Mailing Address
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Address Line | 986 HIGHWAY 48 E
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City | TYLERTOWN
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State | MS
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Zip | 39667-7115
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | JOHN-5CVAJZ
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License Number State | MS
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